Gynaecology sans FrontièresBMJ 2006; 333 doi: https://doi.org/10.1136/bmj.39028.439907.DB (Published 09 November 2006) Cite this as: BMJ 2006;333:990
Patients in Mulago Hospital, Kampala, often lie down in British beds, have x ray pictures taken on British machines, and have their operations on British operating tables. The reason? When London's Middlesex Hospital closed last year, most of the hospital's furniture and equipment was shipped out to Mulago Hospital at the request of the Ugandan hospital's director and through the efforts of Professor Ian Jacobs, a practising gynaecologist and oncologist, whose concept of medicine is a truly international one.
Enticed away from Barts Hospital in 2004 by the promise of having his own institute for women's health at University College London (UCL), Jacobs not only runs the new organisation but is also responsible for one of the largest clinical trials in the world (to discover a screening test for ovarian cancer) and takes time off from his London commitments to work with doctors and healthcare workers in Uganda.
He and his team have devised 12 projects there, including cervical cancer screening, prevention of postpartum bleeding, and neonatal resuscitation, which are set to continue for at least three years. They have also built a hostel for radiotherapy patients at Mulago Hospital and provided funding for a chair of palliative care at Makerere University, and in October they held a meeting in Kampala on women's health that involved 400 health professionals from all over the country.
So how did Jacobs arrive at his present position as founder and director of UCL's Institute for Women's Health and as an adviser to the Ugandan health service?
An interest in research came early in his career. Within a few of years of graduating from the Royal London Hospital in 1983 he was attracted to the idea of researching cancer prevention.
“Although I found clinical medicine incredibly rewarding and important, it does not make fundamental change, and there will always be a constant flow of patients who need you. The best way to make real change and try to stop the flow of patients seemed to me to be research in prevention and screening,” he says.
His enthusiasm for research was fuelled after he saw the dismal outcomes for many women with ovarian cancer on whom he operated at the Royal London in the 1980s. He admits that his timing could not have been better. Fortuitously, the possibility of using the tumour marker CA125 and ultrasonography as screening tools for the disease had recently been raised, and he set to work applying them and getting a training in laboratory science and molecular genetics of cancer alongside his surgical training.
But where was the funding to come from? This was the 1980s, before Bob Geldof made charitable causes fashionable, recalls Jacobs. Surrounded by the office blocks of the City of London, however, he struck on the idea of writing to the top 100 companies asking for financial support for the Gynaecology Cancer Research Fund, a charity he set up to fund his work and that now runs the Eve Appeal, which is dedicated to funding research into gynaecological cancers. He expected to raise enough to fund himself as a research fellow and perhaps a nurse for three months. But within three weeks he had £30 000 (€45 000; $57 000), and senior staff at the Royal London were asking what he planned to do with it.
Twenty years later Jacobs has lost nothing of his drive to “make life better for women with ovarian cancer.” Since his original study of 1010 women was published in the Lancet (1988;i:268-71), his belief in a screening tool for ovarian cancer has been strengthened by the results of his research team, first at the Royal London and later at Barts Hospital after the two hospitals merged, and now at UCL.
In 2001, with a grant of £22m from the Medical Research Council, Cancer Research UK, and the Department of Health, Jacobs set up what is thought to be the largest randomised controlled trial ever performed: the United Kingdom collaborative trial of ovarian cancer screening (UKCTOCS). Recruitment to the trial—which is designed to measure the reduction in mortality associated with screening as well as the morbidity, psychological impact, and cost—finished in 2005, resulting in 202 000 women being enrolled.
It is on the back of this trial, which is due to report in 2011 or 2012, that Jacobs hopes and believes a national ovarian cancer screening programme will be born—and will prove at least as effective as the current breast cancer screening programme.
With one of his lifetime's ambitions seemingly well on the road to being realised, Jacobs says that a call from University College London in 2003 to tempt him away from Barts was unexpected. But UCL has always had a “liberal sort of feel,” says Jacobs, which appealed to him, and a reputation for outstanding academic excellence. He realised that his dream to “develop women's health more broadly” might flower at UCL, with its brand new partner hospital and state of the art research facilities. The extent of the opportunity was confirmed when the provost of UCL and the chief executive of UCL Hospital agreed to the establishment of the Institute for Women's Health as part of his move in April 2004.
“The challenge was to build an institute … from lots of separate pockets of excellence in women's health which already existed. Since 2004 we have managed to establish a team of people working closely together, from basic scientists to clinicians, actively involved in a concerted strategy to develop the leading centre for women's health in the country,” says Jacobs.
The institute, which became fully operational in January 2005, has a clear objective: to become Europe's leading centre for women's health and to make a difference to women's health locally and globally. Its 300 clinicians and academic staff work in a series of specialist groups covering research, clinical practice, education, and training. Among the key areas of activity are perinatal brain injury, fetal medicine, reproductive health, adolescent gynaecology, assisted conception, surgical technology, the prevention, screening, and treatment of cancer, cell biology, molecular genetics, social and behavioural research, and developing world initiatives.
The institute currently receives more than £25m in research grants from the Department of Health, Medical Research Council, Cancer Research UK, the Eve Appeal, and other sources.
Jacobs feels that although his specialist clinical training and skills as a surgical gynaecological oncologist have been essential for his career development, it is the opportunities he has had in research and leadership that have been the key to his success.
“What I think I am good at is having new ideas and the energy to push them through. I am a pretty good organiser, and sometimes I can inspire people,” he says.
But he has another important quality: a capacity for remembering names in the way that a good waiter can recount the orders of a table of eight without recourse to a notepad. He litters his conversation with the names of the many people who have contributed to his success.
Among many others he names the leaders in neonatology, maternal health, translational research, proteomics, cancer screening, and reproductive health who are helping to shape the research agenda at the institute. And he delights in recounting the way a meeting with a generous individual led to a £0.5m donation three days later to fund the institute's plans to help improve women's health in a developing country. Uganda was the recipient of those endeavours, and the acknowledgement of others extends there—to the rural midwife, the palliative care doctor, and many others who told the UCL team what help they most wanted.
Jacobs oozes satisfaction about the Ugandan project. Half a million pounds goes five times further in Uganda than in the UK, he says.
But his work in Uganda has not been without a great deal of soul searching. “We have asked ourselves whether it is ethical to do something that is not definitely sustainable. It is a difficult question to answer, but I have taken the view that we should take the chance to do something worthwhile now and work to make it sustainable, rather than have the chance and do nothing until sustainability is guaranteed. We have already made a tangible difference to the lives of some women and their babies, and so far it seems to have been the right decision.”